SUB-POL-002: Confidentiality of substance use information

Policy · SUB-POL-002 · Version 1.0 · Approved by the ASF Expert Committee

Supports: 38.4

At a glance

Information about a person’s substance use is confidential.
It is shared only with the person’s consent or where the law allows.
Each disclosure is recorded with the person, the reason and the date.
Access to records is limited to staff who need it.
Stop and get help straight away if: information about substance use is disclosed to a third party with no consent and no legal basis.

1. Purpose

To protect people who use substances from harm caused by disclosure, and to keep their trust (38.4).

2. Scope

Applies to	Clinical and support staff in the hospital
Locations	All wards, clinics and departments of the facility
When	Whenever the activity described is carried out
Does not apply to	Activities covered by another document listed in section 15

3. Definitions

Term	Meaning
Clinical lead	The doctor or nurse in charge of the area at the time

4. Background

A person who uses substances may fear arrest or stigma if their information is shared. Keeping it confidential, and sharing it only with consent or where the law requires, keeps them coming back to care.

5. Responsibilities

Role	Responsibility	Competence
Clinical director	Owns the confidentiality policy and approves the disclosure rules	Board or governing body
All staff	Keep information confidential and record each disclosure	Clinical director

6. Materials and equipment

Item	Requirement	Condition
Records and forms named in this document	Current version	Checked before use

7. Safety

Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.

8. Before you start

Confirm the forms and equipment named in this document are available and current.

9. Procedure

Step 1. Protect.

Keep records under access controls limited to staff who need them.

Key point: Protected.

Step 2. Check consent.

Before any disclosure, check the person’s consent or the legal basis (PHC-FRM-001).

Key point: Checked.

Step 3. Record.

Record each disclosure with the person, the reason and the date.

Key point: Recorded.

10. Decision points

No decision points in this procedure.

11. Special situations

Situation	Action
Out of hours	Follow the same steps. Use the on-call contact on the wall of the area.

12. Escalation

Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.

13. Monitoring

Measure	Target	Frequency	Owner	If not met
Disclosures with consent or legal basis recorded	100%	Quarterly	Clinical director	Escalate to the board

14. Records

Record	Kept in	Retention
Record named in this document	Patient record or the area file	the period set by the facility’s records policy years

15. Training

Staff are trained in this document at induction and refreshed each year, with a recorded competency check.

16. Related documents

ID	Title	Use
PHC-FRM-001	Shared record access check (existing)	Form

17. Evidence

Reference	Note
E-009	Based on the WHO guidelines for the psychosocially assisted pharmacological treatment of opioid dependence (2009), the WHO Guidelines on HIV and harm reduction for people who inject drugs, and the ASF Ambulatory standard for addiction services.
E-006	ASF Policy Framework v1.2. Adapted.
E-009	ASF Expert Committee consensus.

18. Change history

Version	Date	What changed	Approval
1.0	the date of approval	First version	set Expert Committee approval

E-learning for this document

Records, Confidentiality and Data Protection (T-11)

References

Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)

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